HTA Respiratory Conditions Consultation Request Form

HTA Respiratory Conditions Consultation Request Form

Your health story matters. Start by sharing your main question or concern. The more details you provide about your symptoms, history, and current challenges, the better we can support you in understanding and helping you manage your respiratory condition.
What is your question?
- Name
  
  First NameLast Name
- Email
  example@example.com
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Gender - Required for interpreting normal pulmonary values
- Height and Weight - Required for interpreting normal pulmonary values
- Age - Required for interpreting normal pulmonary values
- Have you been diagnosed with asthma?
- If yes, who diagnosed you and what month and year?
- Have you had a pulmonary function test?
- If yes, when and where?
- Have you been hospitalized for your asthma?
- If yes, When and how often
- Have you been hospitalized for your asthma?
- If yes, When and how often
- Do you have a current written asthma plan?
- Over the last month, how often is asthma limiting your life?
- Over the last month, how often are you feeling short of breath?
- Over the last month, how often are you using your quick-relief inhaler or nebulizer?
- Over the last month, how often do you feel your asthma was controlled?
- List all your asthma medications, types, dosage, and frequency
- Do you use a spacer for your inhalers?
- How many hours in a week do you spend managing your asthma?
- In the last 4 weeks, how many days of work/school/fun/exercise did you miss due to asthma?
- How much money are you spending per month on MEDICATIONS for your asthma?
- How much money are you spending per month on SUPPLIES for your asthma?
- Do you feel financially burdened by asthma cost?
- Do you have the following supplies?
- Are you satisfied with the way your current healthcare team is helping you manage your asthma?
- Please explain why or why not satisfied
- Our initial evaluation is free and will be emailed to you within 48 hours. This is HTAs way of beginning your journey to better health. Chronic conditions require proactive and continuous monitoring, measuring and managing to achieve better outcomes. We invite you to join us with one of our subscriptions and become a partner in our private HTA Zero Communities where you can interact with other HTA members who also receive clinical information and advice from our trusted clinicians.
  
  By submitting this form, you acknowledge that the information provided is accurate to the best of your knowledge and is intended for initial consultation purposes only.
  
  This form does not constitute medical advice, diagnosis, or treatment, and does not create a doctor–patient relationship.
  
  Always seek the advice of your physician or other qualified healthcare provider with questions you may have regarding a medical condition.
  
  If you are experiencing a medical emergency, dial 911 immediately.
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